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CONTENT OF THIS PUBLICATION The information in this publication is subject to change at any time without notice and should not be relied upon as a substitute for professional advice from an experience, competent practitioner in the relevant field NEITHER THE SOCIETY OF CRITICAL CARE MEDICINE, NOR THE AUTHORS OF THE PUBLICATION, MAKE ANY GURANTEES OR WARRANTIES CONCERNING THE INFORMATION CONTAINED HEREIN AND NO PERSON OR ENTITY IS ENTITLED TO RELY ON ANY STATEMENTS OR INFORMATION CONTAINED HEREIN If expert assistance is required, please see the services of an experiences, competent professional in the relevant field Accurate indications, adverse reactions, and dosage schedules for drugs may be provided in this text, but it is possible that they may change Readers must review current package indications and usage guidelines provided by the manufacturers of the agents mentioned Managing Editor: Kathy Ward Editorial Assistant: Danielle Stone Printed in the United States of America First Printing, September 2016 Society of Critical Care Medicine Headquarters 500 Midway Drive Mount Prospect, IL 60056 USA Phone +1 847 827-6869 Fax +1 847 827-6886 www.sccm.org International Standard Book Number: 978-1-620750-54-4 Contributors Sergio L Zanotti-Cavazzoni, MD, FCCM Editor Chief Medical Officer, The Intensivist Group, Sound Physicians Houston, Texas, USA No disclosures Richard M Pino, MD, PhD, FCCM Editor Associate Professor of Anesthesia, Harvard Medical School Division Chief of Critical Care Vice Chairman for Regulatory Affairs Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Boston, Massachusetts, USA American Society of Anesthesiology; Association of University Anesthesiologists Johanna Wenninger Acosta, MD Critical Care Fellow Cooper Medical School of Rowan University Camden, New Jersey, USA No disclosures Gustavo G Angaramo, MD Associate Professor of Anesthesiology and Critical Care Department of Anesthesiology University of Massachusetts Medical School Worcester, Massachusetts, USA No disclosures Sergio J Anillo, MD Director, Medical Intensive Care Unit Erie County Medical Center Buffalo, New York, USA Upstate New York Transplant Services – Organ Advisory Board Member Edward A Bittner, MD, PhD, MSEd, FCCP, FCCM Assistant Professor of Anesthesia, Harvard Medical School Program Director, Critical Care-Anesthesiology Fellowship Associate Director, Surgical Intensive Care Unit Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Boston, Massachusetts, USA Chair MOCA Minute-Critical Care Committed for the American Board of Anesthesiology Renato Blanco, Jr, MD Critical Care Fellow Cooper Medical School of Rowan University Camden, New Jersey, USA No disclosures David W Boldt, MD Assistant Clinical Professor Division of Critical Care Department of Anesthesiology and Preoperative Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles, California, USA No disclosures Samuel Cemaj, MD, FACS Associate Professor of Surgery University of Nebraska Medical Center Omaha, Nebraska, USA No disclosures Matthew Dettmer, MD Associate Staff Department of Critical Care Medicine Cleveland Clinic Cleveland, Ohio, USA No disclosures Brian M Fuller, MD, MSCI Assistant Professor of Emergency Medicine and Anesthesiology – Critical Care Medicine Washington University in St Louis School of Medicine St Louis, Missouri, USA No disclosures Rajesh R Gandhi, MD, PhD, FACS, FCCM Trauma Medical Director John Peter Smith Hospital Associate Professor of Surgery University of North Texas Fort Worth, Texas, USA Member – EAST, ACS, AAST, TMA, TCMS Shivani Gandhi, DO Internal Medicine Resident Cooper Medical School of Rowan University Camden, New Jersey, USA No disclosures Megan Gooch, MD Internal Medicine Resident Cooper Medical School of Rowan University Camden, New Jersey, USA No disclosures Diana Goodman, MD Attending Physician Department of Neurology Maine Medical Center Scarborough, Maine, USA American Academy of Nephrology – Membership Research Committee Vadim Gudzenko, MD Assistant Clinical Professor Division of Critical Care Department of Anesthesiology and Preoperative Medicine David Geffen School of Medicine at University of California, Los Angeles Los Angeles, California, USA No disclosures W Alan Guo, MD, PhD, FACS Associate Professor of Surgery Division of Trauma, Critical Care and Acute Care Surgery Jacobs School of Medicine and Biomedical Sciences University of Buffalo, New York Buffalo, New York, USA No disclosures Randeep S Jawa, MD, FACS, FCCM Clinical Professor of Surgery Division of Trauma, Critical Care, Emergency Surgery Stony Brook University School of Medicine Stony Brook, New York, USA EAST; COT/ACS, Pediatric Trauma Society, AAST, MSF Erik Kistler, MD, PhD Associate Professor Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures Sandeep Mallipattu, MD Assistant Professor Department of Medicine Division of Nephrology Stony Brook Medicine Stony Brook, New York, USA No disclosures Angela Meier, MD Assistant Clinical Professor Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA Millennium Health – consultant on PRN basis; IARS – mentored research grant Anushirvan Minokadeh, MD Clinical Professor Vice Chair of Critical Care Medicine Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures Lawrence Nelson, DO, FACOS Trauma/Critical Care/General Surgeon North Oaks Shock Trauma Hammond, Louisiana, USA No disclosures Beverly J Newhouse, MD Associate Professor in Anesthesia and Critical Care Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures Albert Phan Nguyen, MD Assistant Clinical Professor Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures E Orestes O’Brien, MD Associate Clinical Professor Clinical Chief, Anesthesiology Critical Care Medicine, Thornton and Sulpizio Hospitals Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures Christopher Palmer, MD Assistant Professor of Emergency Medicine and Anesthesiology – Critical Care Medicine Washington University in St Louis School of Medicine St Louis, Missouri, USA No disclosures Kimberly Pollock, MD Anesthesia Critical Care Fellow Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures Shaji Poovathoor, MD Associate Professor of Clinical Anesthesia Department of Anesthesiology Stony Brook University Hospital Stony Brook, New York, USA No disclosures Nitin Puri, MD, FCCP Associate Professor of Medicine Cooper Medical School of Rowan University Program Critical Care Medicine Camden, New Jersey, USA American College of Chest Physicians – Diversity Committee Fred Rincon, MD, MSc, MB, Ethics, FACP, FCCP, FCCM Associate Professor of Neurology and Neurological Surgery Thomas Jefferson University Department of Neurological Surgery Division of Critical Care and Neurotrauma Philadelphia, Pennsylvania, USA Bard Medical Consultant; Portola Pharmaceuticals Consultant; Neurocritical Care Society Board of Directors Kimberly S Robbins, MD Assistant Clinical Professor of Anesthesiology Program Director, Anesthesiology Critical Care Medicine Fellowship University of California, San Diego, Medical Center San Diego, California, USA No disclosures Aviral Roy, MD Critical Care Fellow Cooper Medical School of Rowan University Camden, New Jersey, USA No disclosures Ulrich Schmidt, MD, PhD, MBA Clinical Professor Department of Anesthesiology University of California, San Diego, Medical Center San Diego, California, USA No disclosures Ahmed Sesay, MD Pulmonary and Critical Care Fellow University of North Carolina Chapel Hill Chapel Hill, North Carolina, USA No disclosures Matthew Sigakis, MD Clinical Lecturer Department of Anesthesiology Division of Critical Care University of Michigan Medical School Ann Arbor, Michigan, USA No disclosures Paul M Strachan, MD Clinical Associate Professor Director, Stony Brook Pulmonary Hypertension Center Division of Pulmonary, Critical Care Medicine Department of Medicine Stony Brook Medicine Stony Brook, New York, USA Shareholder: Pfizer, Portola, Seattle Genetics; United Therapeutics/Lung Biotechnology, Gilead Sciences, InterMune, Boehringer Ingelheim; Clinical Trials: United Therapeutics, Actelion, Bayer, Sanofi Christopher R Tainter, MD, RDMS Assistant Clinical Professor Department of Emergency Medicine Department of Anesthesiology, Division of Critical Care Director of ED Advanced Resuscitation Training Director of Anesthesiology Critical Care Ultrasound University of California, San Diego San Diego, California, USA No disclosures Lisa M Voigt, PharmD, BCPS, BCCCP Clinical Pharmacy Coordinator Critical Care/Infectious Disease Buffalo General Medical Center Buffalo, New York, USA New York State Council of Health-system Pharmacists Board of Directors Brian T Wessman, MD, FACEP Assistant Professor or Emergency Medicine and Anesthesiology – Critical Care Medicine Washington University in St Louis School of Medicine St Louis, Missouri, USA No disclosures Susan Wilcox, MD Associate Professor of Medicine Division of Pulmonary, Critical Care, Allergy and Sleep Medicine Division of Emergency Medicine Medical University of South Carolina Charleston, South Carolina, USA No disclosures Brian Wright, MD, MPH, FACEP, FAAEM Clinical Assistant Professor Departments of Emergency Medicine and Neurosurgery Program Director, Advanced Resuscitation Program Stony Brook University School of Medicine Stony Brook, New York, USA No disclosures Kimberly Zammit, PharmD, BCPS, BCCCP, FASHP Clinical Coordinator, Critical Care/Cardiology Kaleida Health/Buffalo General Medical Center Buffalo, New York, USA No disclosures Contents Items Part – Renal, Endocrine, and Metabolism Disorders in the ICU Part – Cardiovascular Critical Care Part – Pulmonary Critical Care Part – Critical Care Infectious Diseases Part – Gastrointestinal Disorders Part – Neurological Disorders Part – Hematologic and Oncologic Disorders Part – Surgery, Trauma, and Transplantation Part – Pharmacology and Toxicology Part 10 – Research, Ethics, and Administration Rationales Part – Renal, Endocrine, and Metabolism Disorders in the ICU Part – Cardiovascular Critical Care Part – Pulmonary Critical Care Part – Critical Care Infectious Diseases Part – Gastrointestinal Disorders Part – Neurological Disorders Part – Hematologic and Oncologic Disorders Part – Surgery, Trauma, and Transplantation Part – Pharmacology and Toxicology Part 10 – Research, Ethics, and Administration can range from sluggish to dilated, and is nonspecific While hyponatremia can occur, it is usually not this severe The normal white blood cell count also argues against infection In this patient, it would not have been unreasonable to perform a lumbar puncture to exclude acute bacterial meningitis, but the lack of other findings suggestive of meningitis makes it a less likely diagnosis References: White MC How MDMA’s pharmacology and pharmacokinetics drive desired effects and harms J Clin Pharmacol 2014 Mar;54(3):245-252 Hall AP, Henry JA Acute toxic effects of ‘Ecstasy’ (MDMA) and related compounds: overview of pathophysiology and clinical management Br J Anaesth 2006 Jun;96(6):678-685 Sporer KA Acute heroin overdose Ann Intern Med 1999 Apr 6;130(7):584-590 Rationale Answer: A Case series studies have demonstrated that the presenting symptoms of acute kidney injury, rhabdomyolysis, and cardiac dysfunction are associated with propofol infusion syndrome In this setting, rhabdomyolysis occurs from prolonged and high doses of propofol, which eventually can contribute to acute kidney injury Risk factors for propofol infusion syndrome includes prolonged administration with high doses of propofol and concurrent administration of catecholamines and corticosteroids In addition to acute renal failure, propofol infusion syndrome has been associated with severe metabolic acidosis, bradycardia, and cardiovascular instability None of the other options are known to be associated with this clinical presentation References: Wong JM Propofol infusion syndrome Am J Ther 2010 Sep-Oct;17(5):487-491 Diedrich DA, Brown DR Analytic reviews: propofol infusion syndrome in the ICU J Intensive Care Med 2011 Mar-Apr;26(2):59-72 Rationale Answer: D Methylene blue is a known monoamine oxidase inhibitor (MAOI) It is a potent reversible inhibitor of MAO A and, at concentrations reported in the literature after IV administration, MAO B would be partially inhibited but MAO A would be completely inhibited This inhibition of MAO A can lead to disturbances in 5-hydroxytryptamine (5-HT) (serotonin) metabolism, leading to serotonin toxicity (formerly called serotonin syndrome) The patient reported taking scheduled dextromethorphan for a week before surgery The dextromethorphanMAOI interaction appears to be due to 5-HT potentiation In cat studies, dextromethorphan has been shown to markedly enhance the response of noradrenaline and 5-HT but to antagonize the effects of tyramine This suggests that it blocks the uptake of these amines in the adrenergic nerve endings Serotonin toxicity is characterized by increased heart rate, shivering, sweating, dilated pupils, myoclonus (usually more prominent in the lower extremities), hyperreflexia, hyperthermia, hypertension, and agitation Hyperthermia can lead to rhabdomyolysis and renal failure Neuroleptic malignant syndrome usually involves muscle cramps and tremors (not myoclonus), fevers and symptoms of autonomic nervous system instability such as unstable blood pressure, as well as altered mental status These symptoms are most likely caused by blockade of the dopamine receptor D2, leading to abnormal function of the basal ganglia similar to Parkinson disease Symptoms generally come on quickly after the initiation of dopamine antagonists and peak at around three days This patient was taking metoclopramide (a dopamine D2 antagonist) intermittently for nausea and gastroparesis, but had not taken any the morning of surgery The half-life of metoclopramide is five to six hours; therefore, this is a much less likely cause of her symptoms She takes amitriptyline for depression Amitriptyline is a tricyclic antidepressant, which can cause vasodilation, dry mouth, urinary retention, tachycardia, hypotension, and altered mental status, symptoms likely due to the anticholinergic effects of tricyclic antidepressants The treatment is physostigmine She had been taking amitriptyline before surgery There is no reason to believe that she had recently overdosed on it Malignant hyperthermia (MH) is induced by succinylcholine, but is an autosomal dominant disease process characterized by a mutation in the ryanodine receptor on the sarcoplasmic reticulum in skeletal muscle cells, which release calcium in response to increased levels of intracellular calcium, leading to muscle contraction In MH, there is an excessive release of sarcoplasmic reticular calcium leading to prolonged muscle contraction Symptoms of MH include high temperature, increased heart rate, tachypnea, increased carbon dioxide production, increased oxygen consumption, mixed acidosis, rigid muscles, and rhabdomyolysis The first evidence of MH is usually a rise in end-tidal carbon dioxide In this patient, a pure respiratory acidosis is present References: Ramsay RR, Dunford C, Gillman PK Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction Br J Pharmacol 2007 Nov;152(6): 946-951 Sinclair JG Dextromethorphan-monoamine oxidase inhibitor interaction in rabbits J Pharm Pharmacol 1973 Oct;25(10):803-808 Boyer EW, Shannon M The serotonin syndrome N Engl J Med 2005 Mar 17;352 (11):1112-1120 Strawn JR, Keck PE Jr, Caroff, SN Neuroleptic malignant syndrome Am J Psychiatry 2007 Jun;164(6):870-876 Rationale Answer: A Acetaminophen (also called paracetamol) is the most widely used analgesic and antipyretic worldwide Its side effects are generally mild with recommended doses; its use has steadily increased because of its safety profile compared to nonsteroidal antiinflammatory drugs The IV preparation of acetaminophen offers the ability to achieve therapeutic blood concentrations more readily and more reliably, which may be particularly beneficial for use in critically ill patients However, emerging clinical data suggest that IV paracetamol has a propensity to cause hypotension in critically ill patients One of the first studies, by de Maat et al, specifically examined the hemodynamic effects of the new ready-to-use formulation of IV paracetamol It found a decrease in systolic blood pressure of at least 10 mm Hg within 30 minutes of IV administration in one-third of patients Postulated mechanisms for the hypotension include paracetamol-induced increases in skin blood flow (consistent with its antipyretic action) and the effects of mannitol, which is used as a stabilizing agent in the IV formulation Other adverse effects with therapeutic acetaminophen use are rare It can cause transient abnormalities of liver function Very rarely, blood disorders, including drug-induced immune thrombocytopenia, have been reported Pyroglutamic acidosis is a rare adverse effect associated with therapeutic acetaminophen use, most frequently identified in malnourished female patients who have renal insufficiency or failure Acute allergic reactions to acetaminophen are very rarely described Meta-analyses have demonstrated that the addition of acetaminophen to morphine reduces morphine requirements in postsurgical patients by about 20% As a result, acetaminophen is commonly administered along with opioids as part of a strategy of multimodal analgesia References: Boyle M, Nicholson L, O’Brien M, et al Paracetamol induced skin blood flow and blood pressure changes in febrile intensive care patients: an observational study Aust Crit Care 2010 Nov;23(4):208-214 Chiam E, Weinberg L, Bellomo R Paracetamol: a review with specific focus on the haemodynamic effects of intravenous administration Heart Lung Vessel 2015;7(2):121-132 Chiam E, Weinberg L, Bailey M, McNicol L, Bellomo R The haemodynamic effects of intravenous paracetamol (acetaminophen) in healthy volunteers: a double-blind, randomized, triple crossover trial Br J Clin Pharmacol 2016 Apr;81(4):605-612 de Maat MM, Tijssen TA, Brüggemann RJ, Ponssen HH Paracetamol for intravenous use in medium—and intensive care patients: pharmacokinetics and tolerance Eur J Clin Pharmacol 2010 Jul;66(7):713-719 Jefferies S, Saxena M, Young P Paracetamol in critical illness: a review Crit Care Resusc 2012 Mar;14(1):74-80 10 Rationale Answer: A This patient is currently in profound cardiogenic and distributive shock from poisoning with both calcium channel blockade and beta-adrenergic blockade Appropriate first-line therapy remains glucagon and calcium, but in extreme circumstances, high-dose insulin has been shown to be effective However, in the setting of prolonged hypotension, vasopressor support is indicated, with seeming equipoise between epinephrine, norepinephrine, and dopamine Vasopressin also appears to show some benefit, and sometimes multiple vasopressors are required Because of primary distributive shock, venoarterial extracorporeal membrane oxygenation has limited utility Insulin is acting as a chronotrope and inotrope, and is therefore giving him vital hemodynamic support While atenolol primarily does not bind protein in the body, verapamil does exist in the body as a protein-bound drug (about 75%) This makes dialysis a poor management choice for this mixed toxidrome References: St-Onge M, Dubé PA, Gosselin S, et al Treatment for calcium channel blocker poisoning: a systematic review Clin Toxicol (Phila) 2014 Nov;52(9):926-944 Levine M, Curry SC, Padilla-Jones A, Ruha AM Critical care management of verapamil and diltiazem overdose with a focus on vasopressors: a 25-year experience at a single center Ann Emerg Med 2013 Sep;62(3):252-258 11 Rationale Answer: D In a patient with a presentation such as this, with no hard findings of a toxidrome other than depressed mental status, and a very high anion gap, toxic alcohol ingestion must be suspected In this case, the patient drank antifreeze, leading to an ethylene glycol overdose Ethylene glycol is metabolized by alcohol dehydrogenase to glycolic and oxalic acid; methanol is metabolized to formic acid The osmolar gap is useful in diagnosing these ingestions, but not foolproof As the alcohol is metabolized, the osmolar gap narrows and the anion gap increases In this patient, with an anion gap of 38 and a pH of 6.95, significant metabolism has occurred, which accounts for his critically ill state and lack of osmolar gap Also, treatment with ethanol or fomepizole (a competitive inhibitor of alcohol dehydrogenase) will not remove the toxic metabolites, but will aid in the prevention of further accumulation/metabolism of more metabolites This patient needs emergent hemodialysis to correct his life-threatening acidosis, and remove toxic metabolites In addition, adjunctive therapy would include fomepizole until ethylene glycol levels are undetectable, sodium bicarbonate (before dialysis is initiated at least) to enhance formate and oxalate elimination by ion trapping, as well as thiamine and pyridoxine supplementation Another toxic alcohol to consider is isopropyl alcohol, which is found in rubbing alcohol This is metabolized to acetone, which is eliminated in the urine In contrast to ethylene glycol and methanol, isopropyl alcohol will not cause a metabolic acidosis, but has been known to cause nausea, vomiting, and gastrointestinal bleeding, in addition to severe intoxication Reference: Kraut JA, Kurtz I Toxic alcohol ingestions: clinical features, diagnosis, and management Clin J Am Soc Nephrol 2008 Jan;3(1):208-225 12 Rationale Answer: C The clinical examination in brain death is the most unequivocal in neurology It should be performed with care and accuracy In the era of hypothermia, evidence suggests that the best approach before providing prognostic information is to wait for a period of 72 hours after rewarming This is particularly important if the patient has been exposed to sedatives and paralytics in the setting of organ dysfunction, which could confound the clinical examination The American Academy of Neurology practice parameter recommends excluding the presence of a central nervous system (CNS)-depressant drug effect by history, drug screen, calculation of clearance using five times the drug’s half-life (assuming normal hepatic and renal function) or, if available, drug plasma levels below the therapeutic range Prior use of hypothermia (after cardiopulmonary resuscitation for cardiac arrest) may also delay drug metabolism If these two circumstances are present, then longer periods of observation may be needed EEG could be misleading in patients with lingering effects of CNS depressants Neuron-specific enolase is not diagnostic for brain death but could provide prognostic information when used with other variables such as the clinical examination A flow scan would help in the determination of brain death if the physician cannot accurately assess neurologic function after a reasonable period of observation, but it may be premature in this case References: Webb AC, Samuels OB Reversible brain death after cardiopulmonary arrest and induced hypothermia Crit Care Med 2011 Jun;39(6):1538-1542 Nielsen N, Wetterslev J, Cronberg T, et al; TTM Trial Investigators Targeted temperature management at 33°C versus 36°C after cardiac arrest N Engl J Med 2013 Dec 5;369(23):2197-2206 Wijdicks EF, Varelas PN, Gronseth GS, Greer DM; American Academy of Neurology Evidence-based guideline update: determining brain death in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 2010 Jun 8;74(23):1911-1918 Part 10: Research, Ethics, and Administration Instructions: For each question, select the most correct answer Hospital administration has decided to reorganize the provision of critical care services, transitioning to a closed model with interdisciplinary rounds, in an effort to improve care coordination and outcomes Guiding principles for team interactions would benefit from which of the following techniques? A B C D Rapid cycle process Root cause analysis Crew resource management Six Sigma principles An investigator proposes to perform a study to determine the effect of new-onset fever on long-term functional outcome The investigator hypothesizes that fever is associated with poor outcome In order to test the hypothesis, the investigator proposes following the outcomes of febrile patients in the ICU and comparing them to the outcomes of a group of patients without fever during a six-month period The design of this study is best described as which type of study? A B C D E Experimental clinical trial Case-control study Prospective cohort study Retrospective cohort study Ecological study Which of the following practices for decreasing central line-associated bloodstream infections is best supported by evidence? A Cleaning the skin with chlorhexidine before a procedure B Changing central lines every seven days C Multidisciplinary rounds D Preferential placement of internal jugular lines over other sites E Daily blood cultures Which of the following circumstances is most associated with pressure ulcers? A Intermittent hemodialysis B Noninvasive ventilation C Continuous renal replacement therapy D Surgery lasting longer than two hours A 25-year-old man with obesity is admitted to the ICU with sepsis secondary to community-acquired pneumonia Blood pressure is 80/40 mm Hg, heart rate 108 beats/min, respiratory rate 24 breaths/min, pulse oxymetry 90% on 4-liter nasal canula, and lactic acid level 5.6 mmol/L The ICU team requests the patient’s permission to insert a central line through an internal jugular approach to begin pressors After being informed about the indications, risks and benefits, the patient refuses to authorize it and requests that all of the necessary drugs be administered through a peripheral intravenous line The intensivist refuses to administers the pressors through the peripheral IV because of the risk of infiltration with the potential loss of limb The intensivist is exercising which of the following ethical priciples? A B C D Non-abandonment versus nonmaleficence Bioethics versus legal obligation Autonomy versus nonmaleficence Autonomy versus beneficence A 65-year-old woman is evaluated in the emergency department for sudden onset of right hemiparesis and aphasia Blood pressure is 178/106 mm Hg, heart rate 98 beats/min, respiratory rate 24 breaths/min, pulse oxymetry 98% on 2-liter nasal cannula, and National Institutes of Health Stroke Scale score is 16 The on-call neurologist recommends IV recombinant plasminogen activator (rtPA) However, there are no family members with which to discuss potential risks, benefits, or alternatives On the basis of which of the following principles is a physician allowed to administer IV rtPA to this patient? A B C D Autonomy Nonmaleficence Implied consent Utilitarianism A recently published study that followed 30,000 patients during a 20-year period demonstrated that the development of systolic hypertension above 140 mm Hg was associated with doubling of the risk of stroke or transient ischemic attack This study design corresponds to which of the following study types? A Case-control B Cohort C Clinical trial D Cross-sectional E Ecological Part 10 Answers: Research, Ethics, and Administration Rationale Answer: C Efforts to improve care in the medical community have taken a systems approach, recognizing the multidimensional and comprehensive care provided by many individuals to a single patient Crew resource management techniques, long used in the aviation industry to enhance communication skills, decision making, problem solving, and teamwork, along with empowering a greater body of personnel, have served as a model for the collaborative care model of a multidisciplinary ICU team Rapid cycle process and Six Sigma principles are quality management tools used to improve aspects of care and decrease variability in the provision of care and outcomes Root cause analysis is a process used to investigate the central causes of an error in care or a near miss commonly used by hospital risk management departments References: Marshall D Crew Resource Management: From Patient Safety to High Reliability Centennial, CO: Safer Healthcare; 2010 Haerkens M, Jenkins DH, van der Hoeven JG Crew resource management in the ICU: the need for culture change Ann Intensive Care 2012 Aug;2:39-44 Dunn EJ, Mills PD, Neily J, Crittendon MD, Carmack AL, Bagian JP Medical team training: applying crew resource management in the Veterans Health Administration Jt Comm J Qual Patient Saf 2007 Jun;33(6):317-325 Rationale Answer: C A cohort study is a form of longitudinal or observational study designed to look at the association between an exposure and an outcome When the cohort study is begun before the outcome occurs, it is a prospective cohort study If the outcome has already occured, investigators can explore the association by ascertaining the exposure back in time In this case, it is a retrospective cohort study A case-control study is a type of observational study in which two existing groups differing in outcome are identified and compared on the basis of some supposed causal attribute or exposure Controls are selected independent of exposure When the selection occurs on the basis of one characteristic, it is considered a matched study An ecological study is an observational study in which at least one variable is measured at the group level A randomized controlled clinical trial is superior methodology in the hierarchy of evidence in therapy, because it limits the potential for any biases by randomly assigning one patient pool to an intervention and another patient pool to non-intervention or placebo Reference: Porta M, ed A Dictionary of Epidemiology 5th ed New York, NY: Oxford University Press; 2008 Rationale Answer: A Central line-associated bloodstream infections (CLABSIs) are associated with 28,000 deaths in the United States annually and cost 2.3 billion dollars Pronovost et al participated in a project to reduce CLABSIs in the state of Michigan between 2004 and 2005 and demonstrated a reduction in CLABSIs by 66% This project comprised 85% of Michigan’s ICU beds A follow-up analysis at three years demonstrated a sustained improvement A central line bundle incorporated five Centers for Disease Control and Prevention recommendations: hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters A large randomized trial showed that subclavian placement decreased the rate of infection, but is associated with more pneumothoraces No data supports the changing of central lines every seven days or daily blood cultures Multidisciplinary rounds are important in the ICU, but rounding without addressing the need for central lines has not proven to decrease CLABSIs References: Pronovost P, Needham D, Berenholtz S, et al An intervention to decrease catheterrelated bloodstream infections in the ICU N Engl J Med 2006 Dec 28;355(26):27252732 Lipitz-Snyderman A, Needham DM, Colantuoni, et al The ability of intensive care units to maintain zero central line-associated bloodstream infections Arch Int Med 2011 May 9;171(9):856-858 Centers for Disease Control and Prevention (CDC) Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009 MMWR Morb Mortal Wkly Rep 2011 Mar 4;60(8):243-248 Parienti JJ, Mongardon N, Mégarbane B, et al; 3SITES Study Group Intravascular complications of central venous catheterization by insertion site N Engl J Med 2015 Sep 24;373(13):1220-1229 Albrecht RM Patient safety: the what, how, and when Am J Surg 2015 Dec;210(6):978-982 Rationale Answer: B In 2008, the Centers for Medicare & Medicaid Services created incentives for hospitals to prevent pressure ulcers; however, they remain frequent events in ICUs The exact incidence is unclear because of a lack of identification of ulcers on patient admission to the ICU and variations in data reporting The incidence has been reported to vary between 3% and 20% Mechanical ventilation has been associated with an increased incidence of pressure ulcers, secondary to patients being sedentary, and noninvasive ventilation has also been implicated Both intermittent and continuous dialysis have been associated with an increased incidence of pressure ulcers, but surgery lasting longer than two hours has not been associated with it Surgery lasting longer than four hours has been associated with it It is important to identify patients at risk and to develop strategies to prevent pressure ulcers in critically ill patients The Critical Care Pressure Ulcer Assessment Tool Made Easy (CALCULATE) score was developed through literature review and refined through clinical implementation The score consists of risk factors identified through the medical literature for pressure ulcers, including: too unstable to turn, low protein, dialysis, fecal incontenience, mechanical ventilation, long surgery/cardiac arrest during admission, and impaired circulation The score was used over a four-month period, and impaired mobility was added as another risk factor The two most commonly used scales in the United States are the Braden Scale and the Norton Scale Preventing pressure ulcers is important because they increase mortality, morbidity, pain, and hospital costs A multitude of preventive measures exist, but a focused program that ensures excellent communication between leadership and staff seems most vital in decreasing pressure ulcers References: VanGilder C, Amlung S, Harrison P, Meyer S Results of the 2008-2009 International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis Ostomy Wound Manage 2009 Nov 1;55(11):39-45 Richardson A, Barrow I Part 1: Pressure ulcer assessment—the development of Critical Care Pressure Ulcer Assessment Tool made Easy (CALCULATE) Nurs Crit Care 2015 Nov;20(6):308-314 Girard R, Baboi L, Ayzac L, Richard JC, Guérin C; Proseva trial group The impact of patient positioning on pressure ulcers in patients with severe ARDS: results from a multicentre randomised controlled trial on prone positioning Intensive Care Med 2014 Mar;40(3):397-403 Richardson A, Straughan C Part 2: Pressure ulcer assessment: implementation and revision of CALCULATE Nurs Crit Care 2015 Nov;20(6):315-321 Cooper KL Evidence-based prevention of pressure ulcers in the intensive care unit Crit Care Nurse 2013 Dec;33(6):57-66 Rationale Answer: C Ethical principles classically associated with the ethical decision-making process are autonomy, beneficence, nonmaleficence, and legal obligation Autonomy usually takes preference over other factors even though other treatment options are necessary (beneficence) and are explained (legal obligation) Nonmaleficence is the right of the physician to refuse to agree to treatment that would be harmful to the patient The physician cannot abandon a patient who does not agree to treatment until another physician agrees to assume care For this patient, respect of the patient’s wishes (autonomy) and the desire of the physician to not provide an intervention that would be harmful (nonmaleficence) are present References: U.S Department of Health & Human Services Office for Human Research Protections Department of Health, Education, and Welfare The Belmont Report Office of the Secretary Ethical Principles and Guidelines for the Protection of Human Subjects of Research The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research.Washington, DC: U.S Department of Health & Human Services; April 18, 1979 http://www.hhs.gov/ohrp/regulations-andpolicy/belmont-report/ Accessed June 22, 2016 Fisher M Ethical issues in the intensive care unit Curr Opin Crit Care 2004;10:292 Rationale Answer: C In emergency or life-threatening and time-critical situations, physicians have the duty to preserve life In very few life-threatening conditions, such as sepsis or myocardial infarction, patients can be involved in the consent process However, physicians often use an implied consent principle to perform life-saving interventions in patients who lack decision-making capacity or surrogates The emergency doctrine of implied consent allows providers to deliver certain interventions that, if not performed in a timely manner, could potentially lead to increased morbidity and mortality If the following conditions are met, the physician can use the implied consent doctrine: the treatment in question represents the usual and customary standard of care for the condition being treated, it would clearly be harmful to the patient to delay treatment while awaiting explicit consent, and the patient ordinarily would be expected to consent to the treatment in question if he/she had the capacity to so Reference: Bernat JL Ethical Issues in Neurology 3rd ed Philadelphia: Lippincontt Williams & Wilkins; 2008 Rationale Answer: B This study design is a cohort study, in which a population is followed until the development of an outcome The exposure of interest in this case is systolic hypertension Case-control studies are smaller epidemiologic studies in which exposures are actually identified after the onset of an outcome A clinical trial is a study with an experimental design in which two groups are exposed to different interventions, usually a placebo and an experimental drug or procedure Ecological research involves studies of risk-modifying factors on health or other outcomes based on populations defined either geographically or temporally Both riskmodifying factors and outcomes are averaged for the populations in each geographical or temporal unit and then compared using standard statistical methods Reference: Pearce N Classification of epidemiological study designs Int J Epidemiol 2012 Apr;41(2):393-397 ... Endocrine, and Metabolism Disorders in the ICU Part – Cardiovascular Critical Care Part – Pulmonary Critical Care Part – Critical Care Infectious Diseases Part – Gastrointestinal Disorders Part –... Endocrine, and Metabolism Disorders in the ICU Part – Cardiovascular Critical Care Part – Pulmonary Critical Care Part – Critical Care Infectious Diseases Part – Gastrointestinal Disorders Part –... Medical School Program Director, Critical Care- Anesthesiology Fellowship Associate Director, Surgical Intensive Care Unit Department of Anesthesia, Critical Care and Pain Medicine Massachusetts